Gavin Cull

Dasatinib therapy for systemic mastocytosis: four cases.

To the Editor: Systemic mastocytosis (SM) is an uncommon disorder characterised by clonal proliferation and tissue infiltration by mast cells. Effective treatment options for patients with this disease are currently limited. Malignant mast cells are derived from stem cells with activating mutations of the KIT receptor tyrosine kinase (1, 2). The KIT mutation has been implicated in a significant proportion of SM cases (3). Dasatinib (BMS-354825; Bristol-Myers Squibb, New York, NY, USA) is a novel tyrosine kinase inhibitor which has been proven effective in inhibiting D816V positive mast cells in vitro (4, 5). There are currently no published clinical studies evaluating dasatinib in patients with SM. We report four cases of SM treated with dasatinib. The clinical, histological and genetic features of each case are summarised in Table 1. D816V mutation was detected in unfractionated bone marrow cells using a PCR assay (6), while fluorescence in situ hybridisation (FISH) studies were performed for FIP1L1-PDGFRa (7). Mast cell tryptase was measured using the UniCAP 100 (Pharmacia & Upjohn Diagnostics, Uppsala, Sweden) immunoabsorbant assay. Bone marrow trephine biopsies were examined and graded for the extent of involvement by mast cells as outlined in Table 1. Dasatinib was obtained from Bristol-Myers Squibb on compassionate grounds. Case 1 is a 20-year-old female who presented with pruritic skin rash, anorexia, diarrhoea and weight loss of 15 kg (18% of total body weight). Treatment with dasatinib 50 mg daily commenced with concomitant hydrocortisone (100 mg intravenously) and anti-histamine for the first three doses. A moderate exacerbation of skin rash, pruritus and nausea occurred 1 h after the first dose and resolved at 4 d. Dasatinib dose was increased to 50 mg twice daily at 1 month. A moderate reduction in pruritus, improved appetite and weight gain of 10 kg occurred after 6 months, though there was not significant change on repeat bone marrow biopsy. Case 2 is a 52-year-old male who presented with symptomatic pericardial effusion, hepatomegaly and splenomegaly (6 cm). Bone marrow biopsy showed myelodysplasia and diffuse infiltrates of mast cells. Initial treatment with imatinib was not effective and the patient developed moderate diarrhoea and generalised pruritic skin rash. Treatment with dasatinib commenced at 70 mg twice daily with concomitant antihistamines. The patient suffered significantly worse diarrhoea, pruritus and headaches from day 2 to day 5. Complete remission of diarrhoea and skin rash occurred after day 5. Bone marrow examination at 7 months revealed histological response (see Table 1). After 11 months, the patient developed acute myeloid leukaemia and dasatinib therapy ceased. Case 3 is a 60-year-old female who presented with an 18-month history of pruritic skin rash, headaches and lethargy. Early treatment including prednisolone, cladribine, nilotinib, interferon-alpha and splenic radiotherapy was ineffective and the patient developed grade 4 pancytopenia. Dasatinib therapy commenced 5 yr after initial diagnosis. Dose was escalated from 20 mg twice daily to 70 mg twice daily over 3 d, with administration of corticosteroid (hydrocortisone 100 mg intravenously, one dose only) and anti-histamines prior to each dose. Prednisolone 37.5 mg daily was weaned over the following 6 wk. No adverse effects occurred during early treatment. There was no evidence of significant clinical or histological response despite dose increase to 90 mg twice daily and then 110 mg twice daily. Dasatinib therapy ceased after 2 months. Two months later the patient died of complications related to sepsis. Case 4 is a 49-year-old man who was diagnosed with indolent systemic mastocytosis with prominent mast cell degranulation symptoms (ISMSY) after presenting with anaphylactic shock on a background of four previous episodes of anaphylaxis. Interferon-alpha, cladribine, prednisolone and intravenous human immunoglobulin were ineffective and episodes of anaphylaxis occurred with increasing frequency. Dasatinib commenced at 4 yr after diagnosis. Concomitant therapy included ranitidine (ceased with first dasatinib dose), dexchlorpheniramine, sodium cromoglycate, ketolifen and montelukast. No adverse effects were observed. Episodes of anaphylaxis occurred with the same frequency. Dasatinib therapy ceased after 6 months. Dasatinib was generally well tolerated. Cases 1 and 2 suffered early adverse effects that are likely to have been mediated by mast cell mediator release. A similar phenomenon is observed with other cytoreductive agents in SM (8). Cases 3 and 4 showed no response to dasatinib therapy. Both had been heavily pretreated prior to commencing treatment. This small series suggests that dasatinib has some in vivo activity in SM, treating symptoms and reversing disease progression in some patients. The doi:10.1111/j.1600-0609.2008.01048.x European Journal of Haematology ISSN 0902-4441

Safety and efficacy of pegfilgrastim compared to granulocyte colony stimulating factor (G-CSF) supporting a dose-intensive, rapidly cycling anti-metabolite containing chemotherapy regimen (Hyper-CVAD) for lymphoid malignancy.

Pegfilgrastim (Neulasta®) has proven efficacy as supportive therapy in a variety of 21-day chemotherapy regimens, but has not been studied in dose intensive, rapidly cycling regimens utilising cell-cycle active drugs (e.g. anti-metabolites) such as hyper-CVAD. This study examined whether pegfilgrastim was safe and lead to similar kinetics of neutrophil recovery as daily granulocyte colony stimulating factor (G-CSF). Using retrospective analysis, patients receiving pegfilgrastim (6 mg) were matched with controls (G-CSF 5 μg kg−1 per day) for a cycle of chemotherapy, prior chemotherapy, dose of cytarabine received, age (<60 or >60 years), diagnosis and bone marrow involvement. The primary endpoint was duration of grade IV neutropenia (absolute neutrophil count, ANC < 500 μl−1). Secondary endpoints included time to neutrophil recovery, incidence of febrile neutropenia, positive blood cultures and delay in subsequent chemotherapy. This study identified 124 pegfilgrastim supported cycles in 43 patients and successfully matched them to 124 G-CSF supported cycles from 38 patients treated between January 1999 and July 2005. There were no significant differences between pegfilgrastim and G-CSF groups in baseline or treatment-related variables. The median duration of grade IV neutropenia was 4 days in both groups (P = 0.55). Time to neutrophil recovery, incidence of febrile neutropenia, positive blood cultures and delay in subsequent chemotherapy were similar in both groups. Once per cycle dosing of pegfilgrastim appears safe and as effective as daily G-CSF for supporting the hyper-CVAD chemotherapy regimen.

Early treatment intensification with R-ICE and 90Y-ibritumomab tiuxetan (Zevalin)-BEAM stem cell transplantation in patients with high risk diffuse large B-cell lymphoma patients and positive interim PET after 4 cycles of R-CHOP-14

In the treatment of diffuse large B-cell lymphoma, a persistently positive [18F]fluorodeoxyglucose positron emission tomography (PET) scan typically carries a poor prognosis. In this prospective multi-center phase II study, we sought to establish whether treatment intensification with R-ICE (rituximab, ifosfamide, carboplatin, and etoposide) chemotherapy followed by 90Y-ibritumomab tiuxetan–BEAM (BCNU, etoposide, cytarabine, and melphalan) for high-risk diffuse large B-cell lymphoma patients who are positive on interim PET scan after 4 cycles of R-CHOP-14 (rituximab, cyclophosphamide, doxorubicin, and prednisone) can improve 2-year progression-free survival from a historically unfavorable rate of 40% to a rate of 65%. Patients received 4 cycles of R-CHOP-14, followed by a centrally-reviewed PET performed at day 17–20 of cycle 4 and assessed according to International Harmonisation Project criteria. Median age of the 151 evaluable patients was 57 years, with 79% stages 3–4, 54% bulk, and 54% International Prognostic Index 3–5. Among the 143 patients undergoing interim PET, 101 (71%) were PET-negative (96 of whom completed R-CHOP), 42 (29%) were PET-positive (32 of whom completed R-ICE and 90Y-ibritumomab tiuxetan-BEAM). At a median follow up of 35 months, the 2-year progression-free survival for PET-positive patients was 67%, a rate similar to that for PET-negative patients treated with R-CHOP-14 (74%, P=0.11); overall survival was 78% and 88% (P=0.11), respectively. In an exploratory analysis, progression-free and overall survival were markedly superior for PET-positive Deauville score 4 versus score 5 (P=0.0002 and P=0.001, respectively). Therefore, diffuse large B-cell lymphoma patients who are PET-positive after 4 cycles of R-CHOP-14 and who switched to R-ICE and 90Y-ibritumomab tiuxetan-BEAM achieved favorable survival outcomes similar to those for PET-negative R-CHOP-14-treated patients. Further studies are warranted to confirm these promising results. (Registered at: ACTRN12609001077257).

Anaplastic large-cell lymphoma associated with breast implants: A unique entity within the spectrum of peri-implant effusions

Anaplastic large‐cell lymphoma (ALCL) is a rare and newly described complication associated with breast implants. Patients often present with a peri‐implant effusion, which is amenable to fine‐needle aspiration. The laboratory handling of peri‐implant effusions for cytology and ancillary studies is as crucial as recognizing the characteristic cytology of ALCL.

A randomized trial of prophylactic palifermin on gastrointestinal toxicity after intensive induction therapy for acute myeloid leukaemia

Gastrointestinal toxicity, including oral mucositis, is a frequent complication of intensive combination chemotherapy for acute myeloid leukaemia (AML) and contributes substantially to treatment‐related mortality. We conducted a placebo‐controlled randomized trial to evaluate the efficacy of palifermin (keratinocyte growth factor), given at 60 μg/kg per daily IV for 3 d before and after chemotherapy, for mucosal protection in adult patients with previously untreated AML receiving induction therapy with idarubicin, high‐dose cytarabine and etoposide. Among 155 randomized patients, there was no statistically significant difference in the rate of grade 3 and 4 oral mucositis (primary study endpoint) between the two treatment arms (three in palifermin arm (4%), 8 in placebo arm (10%; P = 0·21); however, when considering the severity of oral mucositis (World Health Organization grade 0–4), there was evidence of reduced rates of higher grades of oral mucositis in the palifermin arm (P = 0·0007, test for trend). There was a statistically significantly lower rate of grades 3 and 4 gastrointestinal adverse events in the palifermin arm (21% vs. 44% in placebo arm; P = 0·003), mainly due to a reduction in severe diarrhoea (8% palifermin, 26% placebo; P = 0·01). Palifermin has activity as a mucosal protectant in AML patients receiving intensive chemotherapy. This trial is registered at ACTRN012605000095662.

Prognostic nomogram for diffuse large B‐cell lymphoma incorporating the International Prognostic Index with interim‐positron emission tomography findings

Results from interim‐positron emission tomography (PET) studies in diffuse large B‐cell lymphoma (DLBCL) patients are varied. We evaluated the prognostic value of interim‐PET in our centre. To improve concordance, interim‐PET was combined with the International Prognostic Index (IPI).

Green tea polyphenol “epigallocatechin-3-gallate”, differentially induces apoptosis in CLL B-and T-Cells but not in healthy B-and T-Cells in a dose dependant manner

B-cell chronic lymphocytic leukaemia (CLL) is characterized by an accumulation of CD5-positive monoclonal B-cells due in large part to a failure of apoptosis. The ability to study CLL B-cells in vitro has always been a challenge and hampered by the low viability of the CLL B-cells in cell culture systems. In this study, we present a multicellular cell culture system to maintain CLL B-cells viable in culture for 60h in the presence of a stromal cell feeder layer in combination with a whole white blood cell preparation. Using this optimized system, we tested and showed that the addition of epigallocatechin-3-gallate (EGCG) at concentrations ranging from 25 to 100μg/ml induced apoptosis in CLL B-cells whilst not affecting healthy control B-cells. Moreover, the results showed that in contrast to healthy controls, T-cells from CLL patients underwent apoptosis in the presence of EGCG. This study demonstrated that the combination of a cell feeder layer with a whole white blood cell preparation maintained B-cell viability in vitro over an extended period of time. In addition, the study showed that EGCG differentially induces apoptosis in CLL B-and T-Cells but not in healthy B-and T-Cells in a dose dependent manner.

Idarubicin Dose Escalation During Consolidation Therapy for Adult Acute Myeloid Leukemia

Purpose Higher doses of the anthracycline daunorubicin during induction therapy for acute myeloid leukemia (AML) have been shown to improve remission rates and survival. We hypothesized that improvements in outcomes in adult AML may be further achieved by increased anthracycline dose during consolidation therapy. Patients and Methods Patients with AML in complete remission after induction therapy were randomly assigned to receive two cycles of consolidation therapy with cytarabine 100 mg/m2 daily for 5 days, etoposide 75 mg/m2 daily for 5 days, and idarubicin 9 mg/m2 daily for either 2 or 3 days (standard and intensive arms, respectively). The primary end point was leukemia-free survival (LFS). Results Two hundred ninety-three patients 16 to 60 years of age, excluding those with core binding factor AML and acute promyelocytic leukemia, were randomly assigned to treatment groups (146 to the standard arm and 147 to the intensive arm). Both groups were balanced for age, karyotypic risk, and FLT3-internal tandem duplication and NPM1 gene mutations. One hundred twenty patients in the standard arm (82%) and 95 patients in the intensive arm (65%) completed planned consolidation ( P < .001). Durations of severe neutropenia and thrombocytopenia were prolonged in the intensive arm, but there were no differences in serious nonhematological toxicities. With a median follow-up of 5.3 years (range, 0.6 to 9.9 years), there was a statistically significant improvement in LFS in the intensive arm compared with the standard arm (3-year LFS, 47% [95% CI, 40% to 56%] v 35% [95% CI, 28% to 44%]; P = .045). At 5 years, the overall survival rate was 57% in the intensive arm and 47% in the standard arm ( P = .092). There was no evidence of selective benefit of intensive consolidation within the cytogenetic or FLT3-internal tandem duplication and NPM1 gene mutation subgroups. Conclusion An increased cumulative dose of idarubicin during consolidation therapy for adult AML resulted in improved LFS, without increased nonhematologic toxicity.

High-dose therapy and autologous stem cell transplantation may only be applicable to selected patients with secondary CNS diffuse large B-cell lymphoma

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Differential expression of the Bcl-2 and Bax isoforms in CD19 positive B-lymphocytes isolated from patients diagnosed with chronic lymphocytic leukaemia

Aim: To examine the relative gene expression levels of the anti-apoptotic Bcl-2&agr; and &bgr; isoforms and the pro-apoptotic Bax&agr; and &bgr; isoforms in patients with chronic lymphocytic leukaemia (CLL) and healthy controls (HC). Methods: Peripheral blood was obtained from 36 patients diagnosed with CLL and 10 HC. CD19+ B-lymphocytes were isolated using an antibody coupled magnetic bead isolation system; from these cells the total RNA was isolated and purified. The relative levels of gene expression were examined by quantitative real-time polymerase chain reaction (qReTi-PCR) using primers specific for each isoform. Results: Bcl-2&agr; and Bax&agr; are expressed at higher levels than their &bgr;-isoforms in CLL and HC. Bcl-2&agr;, Bcl-2&bgr; and Bax&bgr; expression is increased in CLL while Bax-&agr; is expressed at similar levels to HC. The Bcl-2&agr;/Bcl-2&bgr; ratio is similar in CLL and HC. The Bcl-2&agr;/Bax&agr; ratio is increased in CLL when compared with HC. Conclusion: Bcl-2&agr; and Bax&agr; appear to be the dominant anti- and pro-apoptotic isoforms in CLL. The Bcl-2&agr;/Bax&agr; ratio is increased in CLL while the Bcl-2&agr;/Bcl-2&bgr; ratio is similar to HC.